| Hepatolithiasis has a high morbidity in southern of China,especially in the southern area of China. According to report for 1859 cases of cholelithiasis, 50% cases were primary bile duct stone, among these patients, 30% cases were concomitance with intrahepatic bile duct stone. The therapeutic efficacy of Hepatolithiasis has been prominently improved in recent years because of the development of image diagnostic technology, perioperative management and surgical skills. This study is to improve the prognosis of Hepatolithiasis by summarizing its experiences of the diagnosis and the treatment.ObjectivesA database using Microsoft Access 2000 was constructed to store all the clinical information of Hepatolithiasis cases. The application value of this information was investigated, and the clinical diagnosis value of surgical treatment was explored using magnetic resonance cholangiopancreatography (MRCP) . Moreover, the results of the surgical treatment of Intrahepatolithiasis were evaluated. Finally, to improve the level of diagnoseis and treatment of intrahepatic cholangiocarcinoma (HLAIHCC), the change of p53 protein expression in HLAIHCC was explored.MethodsA retrospective study was conducted for hepatolithiasis from 1993 to 2004 in ZhuJiang Hospital. An Access 2000 database, the specialized Access database of Hepatolithiasis, consisting of these 326 pathologically confirmed hepatolithiasis cases was established. Using the heavily T2- weighted, 2D, multi-slice, FSE technique, the MRCP examinations were performed on the 1.5T, GE MR system. Axial,gradient-echo (FMSPGR) images were obtained upon the upper abdomen. One of these images through the portahepatis was chosen for localization, the images were obtained the region of the biliary tract with the application of frequency selective fat-suppression. We retrospectively reviewed the medical records of 36 patients who were treated by MRCP for the evaluation of suspected hepatolithiasis from April 1998 to May 2004, (and) who also underwent surgical exploration. Compared results of examined by MRCP with results of operation, the value of qualitative and orientative diagnosis MRCP were evaluated before operation retrospectively.A retrospective analysis of 326 admitted Hepatolithiasis patients who were treated in ZhuJiang hospital from January 1993 to June 2004, including patient age, gender, preoperative evaluation, operative findings, treatment modalities, and postoperative courses was undertaken. The clinicopathological features and surgical cases of the clinical data of 26 patients, who were admitted to our hospital from Jan 1993 to Nov 2004 with HLAIHCC, were analyzed, and p53 protein expression were detected by ABC immunohistochemistry.Results(1) The database system has been successfully constructed and operates smoothly. It is a simplicity and practicality database to construct of hepatolithiasis.(2) 142 of the 326 patients were male and 184 were female, with a mean age of 47 (range, 20-88 ). Among these patients, 134(41.1%) were with intrahepatobiliary tract stones on the left side, 67 (20.6%) on the right side, and 125(38.4%) on both sides. All 326 patients were examined with B-mode ultrasonography(100%). Furthermore, 182 cases were examined with computerized tomography (CT), 55 cases with percutaneous transhepatic cholangiography (PTC), 69 cases with endoscopic retrograde cholangiopancreatography (ERCP), and 36 cases with Magnetic Resonance Cholangiopancreatography (MRCP). A total of 81(24.8%) patients had the complication of biliary tract stricture. In point of view of treatment, 31 out of 326 cases were performed common bile duct exploration combined with T tube drainage;) hepatectomy was performed in 53 cases; hepatectomy and cholangiojejunostomycombined with T tube drainage was performed in 71 cases ; hepatectomy, hepaticolithotomy and hepaticoplasty (on narrow bile duct)combined with hepatocholangiojejunostomy and T tube drainage were performed in 48 cases, bile duct exploration combined with cholangiojejunostomy and T tube drainage were performed in 54 cases, and bile duct exploration combined with subcutaneous tunnel and cholangiojejunostomy, T tube drainage were performed in 27 cases.The rate of residual stones with hepatolobectomy, superior position cholangiojejunostomy, cholangiojejunostomy and exploration of bile duct was 8.7%, 25.8%, 32.1% and 57.1%, respectively. After the operation, complications occurred in 10.1%. The postoperative follow-up for 10 month to 11 years showed that the rate of excellent and satisfactory outcome was 93.6%, 87.1%, 86.4%, and 69%. There was a significant difference between curative effects of nonhepatocetomy and that of hepatoectomy (P<0.05). However, there were not differences between hepatectomy with hepatectomy and cholangiojejunostomy (P>0.05). Among of all, 2 cases died after operation due to lung and heart failure, 1 case died after operation due to hepatorenal syndrome. 36 cases occurred postoperative complications, in which majority were subdiaphragmatic infection, biliary fistula and cholangitis. they recovered by unobstructing the draining, using available antibiotics, and performing supportive treatment. Pathology showed cholangiocarcinoma in 26 cases, Among these patients, 11 were with HLAIHCC on the left side, 3 on the right side, and 12 on both sides.(3) Most of all the places had stones where the cancer occurred of HLAIHCC. Pathologically, all of the HLAIHCC were adenocarcinoma. The carcinoma was divided into three types of mass formation, periductal infiltration and intraductal growth. P53 positivity were detected in 53.8% (14/26) of carcinoma specimens by Immunohistochemistry (IHC). Seventeen patients were underwent hepatic lobectomy or extended lobectomy with or without resection of extrahepatic bile ducts. The overall respectability was 65.4 % respectively. In all cases, p53 protein expression was predominantly localized in tumor cells, whereas some stromal cells, endothelial cells, and Intrahepatic bile duct normal tissure adjacent to the cancer tissue stainedweakly. In cancer cells, p53 protein expression was observed mainly in the nuclear envelope. There was no significant correlation between p53 expression and age, sex, histological differentiation type but TNM staging and survival time(P <0.05). The number of patients with TNM stage Hand III HLAIHCC and that with stage IV and IV b was 3 and 11 in the positive group but 8 and 4 in the nagetive group respectively(P<0.05). The survival time was significantly shorter in patients with positive group than in those without nagetive group(P <0.05 =.Conclusions1. The database possesses powerful capacity for information processing of hepatolithiasis. It is beneficial to not only information management of case record but clinical treatment, diagnose, teaching and research.2. In summary, our study showed that MRCP had a high sensitivity, specificity and accuracy, respectively in the diagnosis of hepatolithiasis. MRCP had a diagnostic accuracy similar to that of ERCP, and it has the potential to replace ERCP in the diagnosis of hepatolithiasis. However, cost considerations and the lack of availability of MR may limit its use at present. MRCP is a safe and sensitive technique, and it is helpful to improve the diagnostic accuracy and clearance rate of hepatolithiasis. MRCP can well show biliary anatomy and greatly improve the rate of correct diagnosis of hepatolithiasis. Preoperative MRCP is valuable for the treatment of hepatolithiasis.3. Different operative options should be selected according to the distribution of stones, the degree of liver lesion, and the pathological types. The efficacy of partial resection of liver and partial resection of liver with cholangiojejunostomy is better in surgical treatment of intrahepatobiliary tract stones. The results showed that modern technique and instrument such as MRCP were an important role in the treatment of hepatolithiasis for selected surgical treatment.4. The intrahepatic cholangiocarcinoma is closely related to long term irritation of hepatolithosasis, inflammations and infections. An aggressive operative approach isadvocated. The expression of p53 protein is significantly correlated to and TNM stage and survival time of HLAIHCC. Its high expression is of potential value in judging progression of HLAIHCC, and it can be used as a marker to evaluate the prognosis of HLAIHCC. |
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